MEDICARE: DYNAMIC PHYSICIAN GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1033077078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC PHYSICIAN GROUP LLC

Provider Business Mailing Address
First Line	:	2200 SHADOWLAKE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7440
Country	:	US
Telephone Number	:	405-342-0143
Fax Number	:	405-260-8784

Provider Business Practice Location Address
First Line	:	2200 SHADOWLAKE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7440
Country	:	US
Telephone Number	:	405-554-3344
Fax Number	:	405-694-4547

Authorized Official
Title or Position	:	MD
Name	:	JEANIE MARIE LOPER
Credential	:
Telephone Number	:	580-916-2494

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	05/28/2026

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